Colorectal cancer (CRC) prevention is a top VA priority. The effectiveness of screening colonoscopy in CRC prevention relies on its quality. The adenoma detection rate (ADR), defined as the proportion of screening colonoscopies performed by a physician that has one or more histologically-confirmed adenomatous polyps or CRC, is the primary benchmark for colonoscopy inspection quality. Increased ADR correlates with a lower risk of CRC incidence and mortality in large studies, including our recent VA data. An Office of the Inspector General (OIG) report highlighted colonoscopy quality deficiencies in VA, and strongly recommended that the ?Acting Under Secretary for Health require standardized documentation of quality indicators based on professional society guidelines and published literature.? Currently, VA cannot ensure Veterans receive high quality colonoscopy for CRC prevention, as there is no automated mechanism to continually measure or report quality. We have developed the novel informatics infrastructure for centralized colonoscopy quality reporting across VA, enabling implementation of the VA Endoscopy Quality Improvement Program (VA-EQuIP) to directly address the OIG recommendations and VA?s critical need to implement evidence-based colonoscopy quality measurement and reporting. The National Gastroenterology (GI) program office will implement VA- EQuIP to provide VA sites and endoscopists with bi-annual audit and feedback of colonoscopy quality with individual provider benchmarking to local and national performance and collaborative learning sessions moderated by national experts in colonoscopy training and quality. The implementation of a novel program, such as VA-EQuIP, is an opportunity to study the impact of a large-scale learning health system initiative. The specific aims of this service directed research proposal are: Aim 1: To determine if implementation of VA-EQuIP increases provider adenoma detection rates compared to usual care. Aim 2a: To evaluate VA-EQuIP implementation and identify site level factors associated with colonoscopy quality improvement. Aim 2b: To explore and identify components of provider behavior change after VA-EQuIP implementation. We propose to evaluate the effect of VA-EQuIP implementation on colonoscopy performance using a cluster randomized controlled trial to determine the efficacy of the intervention on overall ADRs and provider-level ADRs. We will use a mixed-methods approach to evaluate the intervention in a multi-faceted manner to evaluate implementation outcomes and components of provider behavior change. We are powered to identify improvements in ADR of at least 1% for providers. This effect is clinically important, because each 1% increase in ADR is associated with a decreased risk of 3% for CRC incidence and 5% for CRC death. Our approach to standardized, transparent, automated quality reporting, coupled with collaborative learning, is a key initial step to improve colonoscopy quality. We postulate that the collaborative learning sessions will help drive peer-to- peer and peer-to-expert learning to impact quality improvement in a non-punitive forum, while maintaining local autonomy. A critical next step will be to provide access to more intensive interventions, such as site visits and one-on-one, hands-on training, for persistently low performing providers based on findings from our evaluation. In addition, in collaboration with the Office of Veterans Access to Care, VA-EQuIP can ensure that access initiatives are focused on providing Veterans with high quality procedures.